What is the most appropriate management for an elderly patient with diabetes mellitus, hypertension, and dyslipidemia, who had a recent ischemic stroke and now presents with fatigue and hyperglycemia?

Management of Hyperglycemia in Post-Stroke Diabetic Patient

The most appropriate management is subcutaneous insulin therapy (not insulin infusion), targeting blood glucose levels of 140-180 mg/dL, as this approach balances glycemic control with the critical need to avoid hypoglycemia in this elderly, high-risk patient. 1

Why Not the Other Options

• Warfarin (Option A) is incorrect because this patient is already on antiplatelet therapy, and there is no indication mentioned for anticoagulation (such as atrial fibrillation or cardioembolic source). The question focuses on managing hyperglycemia, not stroke prevention modification. 2

• Observation alone (Option B) is inappropriate because persistent hyperglycemia >200 mg/dL during the first 24 hours after stroke independently predicts expansion of infarct volume and worse neurological outcomes. Active glucose management is required. 2, 1

• Insulin infusion (Option C) is unnecessarily aggressive for this non-ICU patient presenting 2 weeks post-stroke with hyperglycemia. Continuous insulin infusion is reserved for critically ill ICU patients or those requiring glucose levels <180 mg/dL with intensive monitoring. 2

Recommended Treatment Approach

Initiate subcutaneous basal-bolus insulin regimen:

• Start with 0.3 units/kg/day total daily dose, divided as half basal insulin (once daily) and half rapid-acting insulin before meals if oral intake is adequate 1
• Target glucose range of 140-180 mg/dL to balance efficacy with hypoglycemia risk, which is particularly important in elderly patients with recent stroke 2, 1
• The American Heart Association/American Stroke Association specifically recommends treating elevated glucose in the range of 140-180 mg/dL in stroke patients 1

Critical Safety Monitoring

Hypoglycemia prevention is paramount in this elderly patient:

• Monitor glucose every 6 hours initially 1
• Check potassium levels before and during insulin therapy to avoid hypokalemia 1
• Avoid glucose levels <80 mg/dL, as hypoglycemia may be more immediately dangerous than moderate hyperglycemia in elderly diabetic patients with recent stroke 2, 1
• Elderly patients often fail to perceive hypoglycemic symptoms and have impaired counterregulatory responses, increasing risk of severe hypoglycemic events 2

Why This Approach for Post-Stroke Patients

Hyperglycemia worsens stroke outcomes through multiple mechanisms:

• Increases tissue acidosis through anaerobic glycolysis and lactic acidosis 2, 1
• Promotes free radical production and affects the blood-brain barrier 2, 1
• Increases brain edema risk and hemorrhagic transformation of infarction 2, 1
• Persistent hyperglycemia >200 mg/dL during the first 24 hours independently predicts infarct expansion 2, 1

Common Pitfalls to Avoid

• Never use sliding-scale insulin alone as the single regimen, as it results in undesirable hypoglycemia and hyperglycemia with increased risk of hospital complications 1
• Avoid overly aggressive glucose targets (<140 mg/dL) in elderly patients, as the risk of hypoglycemia outweighs potential benefits 2
• Do not use chlorpropamide if considering oral agents, as it has prolonged half-life in elderly patients and increases hypoglycemia risk 1
• Recognize that elderly hospitalized patients have multiple risk factors for hypoglycemia including renal failure, malnutrition, and impaired counterregulatory responses 2

Timing Considerations

While this patient presents 2 weeks post-stroke (not in the acute hyperacute phase), persistent hyperglycemia still requires treatment to prevent ongoing vascular damage and optimize recovery. 2 The subcutaneous insulin approach is appropriate for this non-critical timeframe, whereas insulin infusion would have been considered only during the acute stroke period with glucose >180 mg/dL requiring ICU-level monitoring. 2